When do I dose reduce Eliquis (apixaban)?

From the Guidelines

You should reduce the standard dose of Eliquis (apixaban) from 5mg twice daily to 2.5mg twice daily if you have at least two of the following factors: age 80 years or older, body weight of 60kg (132 pounds) or less, or serum creatinine of 1.5mg/dL or higher, as recommended by the most recent guidelines 1. When considering dose reduction for Eliquis, it's essential to evaluate the patient's renal function, age, weight, and medication interactions.

• The dose reduction criteria are based on the presence of at least two of the following factors: age ≥80 years, body weight ≤60 kg, or serum creatinine ≥1.5 mg/dL 1.
• Patients with severe renal impairment, specifically those with creatinine clearance between 15-29 mL/min, may also require dose reduction 1.
• Additionally, concomitant use of certain medications that strongly affect apixaban's metabolism, such as ketoconazole, itraconazole, ritonavir, or clarithromycin, may necessitate dose adjustment 1.
• It's crucial to consult a healthcare provider before making any changes to the Eliquis dose, as improper dosing can lead to serious complications like increased bleeding risk or reduced effectiveness in preventing blood clots.
• The healthcare provider will monitor the patient's kidney function, weight, age, and medication interactions to determine if dose adjustment is appropriate for their specific situation 1.

From the FDA Drug Label

For patients receiving apixaban tablets doses of 5 mg or 10 mg twice daily, reduce the dose by 50% when apixaban tablet is coadministered with drugs that are combined P-glycoprotein (P-gp) and strong cytochrome P450 3A4 (CYP3A4) inhibitors (e.g., ketoconazole, itraconazole, ritonavir) [see Clinical Pharmacology (12.3)]. In patients already taking 2. 5 mg twice daily, avoid coadministration of apixaban tablets with combined P-glycoprotein (P-gp) and strong CYP3A4 inhibitors [see Drug Interactions (7.1)].

You should dose reduce Eliquis (apixaban) when it is coadministered with combined P-gp and strong CYP3A4 inhibitors. The dose should be reduced by 50% for patients receiving 5 mg or 10 mg twice daily. For patients already taking 2.5 mg twice daily, coadministration with these inhibitors should be avoided 2.

From the Research

Dose Reduction Criteria for Apixaban (Eliquis)

• The decision to dose reduce apixaban is based on specific patient criteria, including age, weight, and renal function 3, 4.
• Patients who meet 2 of 3 criteria (age ≥80 years, body weight ≤60 kg, and serum creatinine ≥1.5 mg/dL) are recommended to receive reduced-dose apixaban 3.
• Alternative definitions based on age and renal function alone may be used when patient weight is not available 3.

Factors Associated with Inappropriate Dose Reduction

• Age, patient weight, and serum creatinine level are independent predictors for apixaban underdosage 4.
• In clinical practice, apixaban dosing is frequently inconsistent with labeling, and factors associated with inappropriate dose reduction are the same as those used for dose adjustment 4.

Apixaban Concentrations with Lower than Recommended Dosing

• Apixaban concentrations in older adults with nonvalvular atrial fibrillation (NVAF) are higher than expected based on clinical trial data, even with lower than recommended dosing 5.
• Monitoring of apixaban concentrations may be necessary during care of patients who differ from those in randomized trials or when considering dosing outside of published guidelines 5.

Extended Reduced-Dose Apixaban for Cancer-Associated Venous Thromboembolism

• Extended anticoagulation with reduced-dose apixaban is noninferior to full-dose apixaban for preventing recurrent venous thromboembolism in patients with active cancer 6.
• The reduced dose leads to a lower incidence of clinically relevant bleeding complications than the full dose 6.

Reduced-Dose Apixaban in Special Populations

• Reduced-dose apixaban may be used as an alternative to warfarin in the treatment of left ventricular thrombus, although it is not currently FDA-indicated for this use 7.
• Case reports suggest that reduced-dose apixaban (2.5 mg twice daily) may be effective and safe in certain patients with left ventricular thrombus 7.